Early Identification of Psychosis A Primer Mental Health Evaluation & Community Consultation Unit TABLE OF CONTENTS Introduction...............................................................................................................3 Psychosis and Early Intervention........................................................................4 Why is Early Intervention Needed?...................................................................5 Risk and Onset..........................................................................................................6 Course of First-Episode Psychosis 1. Prodrome........................................................................................................7 2. Acute Phase....................................................................................................8 3. Recovery Phase..............................................................................................9 Summary of First-Episode Psychosis...............................................................11 Tips for Helpers......................................................................................................12 More Resources......................................................................................................15 Acknowledgements...............................................................................................16 2 INTRODUCTION Psychosis is a condition characterized by loss of contact with reality and may involve severe disturbances in perception, cognition, behavior, and feeling. Approximately 3% of people will experience a psychotic episode at some stage in their life. Usually a person’s first episode occurs in adolescence or early adult life, an important time for the development of identity, relationships and long-term vocational plans. The initial episode of psychotic disorders can be particularly confusing and traumatic for the person and their family. A lack of understanding of psychosis often leads to delays in seeking help. As a result, these treatable illnesses are left unrecognized and untreated. Even when appropriate help seeking does occur, further delays in diagnosis and treatment may result from skill and knowledge gaps among professionals. Increasingly, attention is being paid to strategies that reduce the personal, social and economic strain of these conditions on affected individuals, their families and the community. Early intervention in first-episode psychosis is aimed at shortening the course and decreasing the severity of the initial psychotic episode, thereby minimizing the many complications that can arise from untreated psychosis. It is a strategy that can provide considerable long-term benefits. This booklet was developed for mental health workers, school counselors, alcohol and drug professionals, and others working with youth and young adults who may be at risk for psychosis. 3 PSYCHOSIS AND EARLY INTERVENTION Psychosis describes a mental state characterised by distortion or loss of contact with reality. Positive symptoms of psychosis include delusions, hallucinations and/or thought disorder. There are multiple causes of psychosis, which include substance abuse or withdrawal, exposure to severe stress, inherited and acquired medical conditions or diseases, and mood disorders. However, the most common cause of psychosis is schizophrenia. Negative symptoms such as poverty of thought or speech, loss of motivation, and restriction in the range of emotional expression can also occur. In addition, there are usually a number of other 'secondary' features, such as sleep disturbance, agitation, behaviour changes, social withdrawal and impaired role functioning. These secondary features can often provide the clue to the presence of psychosis. Psychosis can be caused by organic causes, intoxication, and “functional” disorders such as schizophrenia, bipolar disorder, schizophreniform psychosis and schizoaffective disorder. Early intervention involves diagnosis of psychotic disorders at the earliest possible time and ensuring that appropriate specialist treatment is initiated. This should be at the first sign of positive psychotic symptoms, but it may also be possible to intervene during the period prior to development of psychotic symptoms (the prepsychotic or prodromal phase). Achieving early intervention requires increasing community understanding of these disorders through raising awareness of early signs and decreasing the stigma which can sometimes delay people from seeking help. Involvement of the family in all phases of the disorder should not be under-emphasized. An educated and committed family is a valuable resource for the individual and the treatment team. 4 WHY IS EARLY INTERVENTION NEEDED? Several studies have shown there is often a major delay in initiating treatment for people affected by a psychotic disorder. These delays vary widely from person to person, but in many studies the interval between onset of psychotic symptoms and commencement of appropriate treatment is more than one year. Poorer Outcomes A psychotic episode commonly isolates the person from others and impairs family and social relationships. Difficulties in school and work performance arise and secondary problems such as unemployment, substance abuse, depression, self harm or suicide and illegal behaviour can occur or intensify. Some evidence shows that long delays in obtaining treatment may cause the illness to become less responsive to treatment. It has been found that delays in receiving treatment are associated with slower and less complete recovery and that long duration of psychotic symptoms before treatment appears to contribute to poorer prognosis and a greater chance of early relapse. Delayed Treatment Can Result in: – Interference with psychological and social development – Strain on relationships or loss of family and social supports – Disruption of parenting role in young mothers/fathers with psychosis – Distress and increased psychological problems within the person's family – Disruption of study – Disruption of employment and unemployment – Slower and less complete recovery – Poorer prognosis – Depression and suicide – Substance abuse – Illegal behaviour – Unnecessary hospitalization 5 – Increased economic cost to the community Benefits of Early Intervention: – Reduced morbidity – Preservation of psychosocial skills – Preservation of family and social supports – Decreased need for hospitalization – More rapid recovery – Better prognosis RISK AND ONSET The stress-vulnerability model for psychosis suggests that the onset and course of psychosis are determined by an underlying vulnerability to psychosis which when coupled with the impact of environmental 'stressors' may then trigger active psychotic symptoms. The major determinants of this vulnerability appear to be biological (genetic and neurodevelopmental) and its expression as disorder is influenced by psychosocial and/or physical stressors. A positive family history of psychosis is associated with an increased risk of vulnerability to psychosis. For example, the risk of developing psychosis associated with schizophrenia is 1% for the general population vs. 13% for the children of those with schizophrenia. An estimated 80% of individuals affected by a psychotic disorder experience their first episode between the ages of 16-30 and the median age of first onset of bipolar disorder and schizophrenia is 19 years, with females having a slightly later age of first episode compared to males. 6 COURSE OF FIRST-EPISODE PSYCHOSIS The typical course of the initial psychotic episode can be conceptualised as occurring in three phases. These are the prodromal phase, the acute phase and the recovery phase. 1. Prodrome The prodromal phase is the period during which the individual is experiencing changes in feelings, thought, perceptions and behaviour although they have not yet started experiencing clear psychotic symptoms such as hallucinations, delusions or thought disorder. Depending on the type of psychotic condition, the prodrome may or may not be apparent. Changes in this phase vary from person to person and some people may not experience a prodromal phase. The duration of this phase is also quite variable, although it is usually over several months. In general, the prodrome is fluctuating and fluid, with symptoms gradually appearing and shifting over time. Some prodromal signs and symptoms include: Changes in Affect: Feelings of vague suspiciousness, depression, anxiety, tension, irritability, anger or mood swings. Changes in Cognition (Thinking): Difficulty in concentration and memory, thoughts feel slowed down or speeded up, odd ideas, vague speech. Changes in Sense of Self, Others or the World: Feeling somehow different from others or that things in the environment may seem changed. Physical and Perceptual Changes: Sleep disturbances, appetite changes, bodily complaints, loss of energy or motivation and perceptual aberrations. Family and friends may notice when: A person's behaviour changes, their studies or work deteriorate, they become more withdrawn or 7 isolated, they are no longer interested in socializing or they become less active. Clearly, these changes are non-specific and can result from a number of psychosocial difficulties, physical disorders and psychiatric disorders. 2. Acute Phase During this period, which will usually continue until appropriate treatment is initiated, the typical psychotic symptoms occur. This includes positive symptoms such as thought disorder, delusions and